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STATE OF CALIFORNIA-' WATER RESOURCES CONTRO`"KOARD <br /> FORM 'A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Y o,<rri �r 10 <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE )..► <br /> 2 INTERIM PERMIT �4 AMENDED PERMIT �6 TEMPORARY SITE CLOSUREffQ —4I. FACILITY/SITE INFORMATION III ADDRESS - (MUST BE COMPLETED) <br /> W <br /> FACILI (SITE NAME - <br /> /G_7/ CARE OF ADDRESSINFORM TyyN <br /> SPry/G c ♦ /G>/P( S <br /> A 40, <br /> DDRESS <br /> NEAREST CROSS STREET ✓ WM ❑ PARMERSIIP ❑ STATE-AGE1#Y <br /> ��aLUR'OKTION ❑ LOCAL-AGENCY ❑ FEDI L_ASSN <br /> CITY NA �^_"" {07L1/�[.T INOMOUAL ❑ CWMAGENC <br /> 10� STATE CODE SITE PHONE a,WITH AREA CODE <br /> TYPE OF BUSINESS: 7 CA O 2 <br /> 2 DISTRIBUTOR PROCESSOR ✓Box if INDIAN EPA ID a <br /> 1 GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ #of TANK' <br /> # <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> ckark< -79- l N <br /> NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 0 6- <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME /c# CARE OF�RESS INFORMATION <br /> DDRESS <br /> MAILING or STREET A •✓8ox to intlicate ❑ PARTNERSHIP 11STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> a 230 20 -8?6 <br /> Ill. TANK OWNER 14FORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G 5 <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L [:] It. ❑ Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY B FACILITY ID N R of TANKS BI SITE <br /> ® O Gz � 10101 0101 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE a WITH AREA CODE <br /> P <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L—j-PE112AMOUNT <br /> E C�E7NSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES NO e*L <br /> SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> \ FORMA(3-2-813) <br /> DATA PROCESSING COPY <br />